How to limit avoidable disability Associate professor Susanne S - - PowerPoint PPT Presentation

How to limit “avoidable” disability

Associate professor Susanne S Hernes Sept.22. 2017

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CONFLICT OF IN INTEREST DIS ISCLOSURE

I have no potential conflicts of interest to report

Avoidable?

Avoidable -> can be prevented from happening

Learning goals

• Understand two different approaches to disability and illness
• Relate this to common diseases in older adults
• Have knowledge of how to limit disability at system level

Important for whom?

Important for whom?

PATIENT CENTERED APPROACH

Important for whom?

PATIENT CENTERED APPROACH DISEASE CENTERED APPROACH

Disease centered approach

Bowling, C. "Managing older adults with CKD: individualized versus disease-based approaches." Am. Journ. of Kidn. Dis 59.2 (2012): 293- 302.

Patient centered approach

Bowling, C. "Managing older adults with CKD: individualized versus disease-based approaches." Am. Journ. of Kidn. Dis 59.2 (2012): 293- 302.

When looking at an organ…

When looking at an organ…

…..remember the macro perspective

Heart failure – patient’s views

• Managing physical symptoms
• Managing treatment
• Information of prognosis/diagnosis
• Progressive losses
• Social isolation
• End of life care

Boyd, Kirsty J., et al. "Living with advanced heart failure: a prospective, community based study of patients and their carers." European journal of heart failure 6.5 (2004): 585-591.

Wal, M. H. L., et al. International journal of clinical practice 70.6 (2016): 469-476.

Survival in Chronic Heart Failure

Wal, M. H. L., et al. International journal of clinical practice 70.6 (2016): 469-476.

Survival in Chronic Heart Failure

No difference between groups in: Left ventricular ejection fraction Coronary artery disease Hypertension Valvular disease Deterioration group more likely to be: Depressed Have COPD Have previous admissions for HF HF for a longer time

Angermann, Christiane E., et al. Jama 315.24 (2016): 2683-2693.

COPD – patient’s views

• Good/bad days
• Breathlessness
• Fatigue
• Restricted ADL
• Pain
• Anxieties
• Fear of dying
• Loss of independence

Giacomini, Mita, et al. "Experiences of living and dying with COPD: a systematic review and synthesis of the qualitative empirical literature." Ontario health technology assessment series 12.13 (2012): 1.

Quality of life and management issues

• Activity limitation
• Airflow obstruction
• Airway inflammation
• Anemia
• Anxiety
• Cardiac dysfunction
• Co-morbidity
• Depression
• Dysfunctional breathing
• Dyspnea
• Exacerbation management
• Exercise intolerance
• Frequent chest infections
• Frequent oral corticosteroids
• Inappropriate drug prescription
• Inadequate Inhaler device technique
• Oxygen desaturation
• Mucus hypersecretion
• Non-adherence to treatment
• Nutrition
• Pathogen colonization
• Smoking
• Systemic inflammation

McDonald, Vanessa M., et al. "Multidimensional assessment of older people with asthma and COPD: clinical management and health status." Age and ageing 40.1 (2010): 42-49.

Quality of life and management issues

McDonald, Vanessa M., et al. "Multidimensional assessment of older people with asthma and COPD: clinical management and health status." Age and ageing 40.1 (2010): 42-49.

Quality of life and management issues

• Activity limitation
• Airflow obstruction
• Airway inflammation
• Anaemia
• Anxiety
• Cardiac dysfunction
• Co-morbidity
• Depression
• Dysfunctional breathing
• Dyspnoea
• Exacerbation managment
• Exercise intolerance
• Frequent chest infections
• Frequent oral corticosteroids
• Inappropriate drug prescrition
• Inadequate Inhaler device technique
• Oxygen desaturation
• Mucus hypersecretion
• Non-adherence to treatment
• Nutrition
• Pathogen colonisation
• Smoking
• Systemic inflammation

McDonald, Vanessa M., et al. "Multidimensional assessment of older people with asthma and COPD: clinical management and health status." Age and ageing 40.1 (2010): 42-49.

• 73% reported inability to achieve

activity goals

• 50% three or more different

inhalers

• 48.5 % inadequate inhaler

technique

• Reduced airflow speed
• Incorrect inhalation pattern

Undernutrition – Patient Perspective

• Soreness
• Lack of memory
• Physiological indifference
• Nausea
• Pain
• Bad taste in mouth

Holst, Mette et al. Scandinavian journal of caring sciences 25.1 (2011): 176-184.

Undernutrition

• 50% of patients hungry during

hospital stay

• Difficulties
• Reaching food
• Managing utensils
• Feeding oneself

Naithani, Smriti, et al. "Hospital inpatients’ experiences of access to food: a qualitative interview and observational study." Health Expectations 11.3 (2008): 294-303.

Feeling hungry while hospitalized?

Undernutrition

Loss of lean body mass: Feeling hungry while hospitalized?

• 50% of patients hungry during

hospital stay

• Difficulties
• Reaching food
• Managing utensils
• Feeding oneself

10% Immune suppression Increased risk of infections 15-20% Impaired wound healing  30% Spontaneous wounds Lack of wound healing Increased risk of pneumonia

Naithani, Smriti, et al. "Hospital inpatients’ experiences of access to food: a qualitative interview and observational study." Health Expectations 11.3 (2008): 294-303.

Altered body composition -> pharmacological challenges

Nutritional intervention

• Malnourished hospitalized individuals
• High protein reduced 90 day mortality and increased nutritional status as

compared with placebo.

• Hip fracture in older adults
• Oral supplements started before or soon after surgery may prevent

complications after hip fracture in older people but may not affect mortality.

Readmission and mortality in malnourished, older, hospitalized adults treated with a specialized oral nutritional supplement: A randomized clinical trial. Deutz. Clinical Nutrition. 2016 Avenell, Alison, and H. H. Handoll. "Nutritional supplementation for hip fracture aftercare in older people." Cochrane Database Syst Rev 1 (2010).

Nutritional support in hospitalized patients at nutritional risk

• Low-quality evidence for the effects of nutrition support on mortality

and serious adverse events.

• Very low-quality evidence for an increase in weight with nutrition

support at the end of treatment in hospitalized adults determined to be at nutritional risk.

• Effects of nutrition support on all remaining outcomes are unclear.
• Future trials ought to be conducted with low risks of systematic errors

and low risks of random errors, and they also ought to assess health- related quality of life.

Feinberg, Joshua, et al. "Nutrition support in hospitalised adults at nutritional risk." The Cochrane Library (2017).

Limiting avoidable disability at system level

Travelling between health care levels

• Consistency of personnel
• Ongoing patient-provider

relationship

• Information transfer
• Accumulated knowledge
• Consistency of care
• Accessibility
• Flexibility

Waibel, Sina, et al. "What do we know about patients' perceptions of continuity of care? A meta-synthesis of qualitative studies." International Journal for Quality in Health Care 24.1 (2011): 39-48.

Ordinary pathway and ward Specialized pathway and ward

Patient’s views - CGA at Acute Medical Unit

• Perceived lack of treatment on the acute medical unit
• Unclear grasp of the role of the geriatrician
• Ongoing needs

Darby, Janet, et al. "Comprehensive geriatric assessment on an acute medical unit: a qualitative study of older people’s and informal carer’s perspectives of the care and treatment received." Clinical rehabilitation 31.1 (2017): 126-134.

Comprehensive Geriatric Assessment

• ↑ likelihood to be home and alive at 3 and 12 months (RR 1.06

(1.01-1.10))

• ↓ likelihood of being admitted to a nursing home at 3 and 12

months (RR 0.80 (0.72-0.89))

• No difference in mortality at 3 and 12 months (RR 1.00 (0.93-

1.07))

Ellis, G., et al. "Comprehensive geriatric assessment for older adults admitted to hospital." status and date: New search for studies and content updated (no change to conclusions), published in 9 (2017).

Take home message

• Remember the patient centered approach!
• Surrounding factors might have a great impact on disease and disease

progression

• Choice of health care system impacts disability

Statement

No older LEGO persons were injured during the preparation of this lecture

QUESTIONS?